CC: SOB
HPI: 80 yo male with sudden onset SOB during walk. Pt recalls feeling sick and then experienced syncopal eposide. Pt denies CP. Denies recent illness.
EXAM: Pale, anxious, diaphoretic. VS: BP: 107/70, P: 107, R: 20. Sp02: 89%. Pt retracting; clear lung sounds.
ASESS: Severe respiratory distress
PLAN: Vitals, 12 lead, high flow oxygen, fluid bolus, 324 mg ASA
12 LEAD ECG
12 LEAD ECG RHYTHM STRIP
EMS and ED COURSE
The providers package the patient for transport. The patient becomes progressively more short of breath. Truncal cyanosis appears and is refractory to high flow oxygen. The patient has seizure-like activity upon arrival to the ED. Compressions are started and the patient expires following thirty minutes of failed reususcitation.
What clues are provided by the patient's history or 12 lead ECG?
Clinical presentation and history of the complaint points me towards a PE, regardless of my ECG findings. Going back to the ECG it looks like we have grouped beating, PRi prolongation, and pauses. Many of the footprints of Wenckebach...except we're missing shortening RR's!
ReplyDeleteLooks like we've got 5:4 Pacemaker Wenckebach at the maximum tracking rate (DDD, MTR=600ms), with a lower rate limit of ~75 bpm? Perhaps rate drop features have bumped the LRL up.
Extremely cool ECG.
Err not "rate drop" but "rate response".
Delete+1 for Pacemaker Wenckebach. Sounds like the patient's critical illness bumped up his sinus rate to an unacceptably high level so the PM's Wenckebach feature kicked in. Next step would be a PM-mediated 2:1 block if the rate continued to climb!
ReplyDelete